MEDICARE: MEL A DERMODY H.I.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	237700000X	Hearing Instrument Specialist	3189	IL

General Provider Information

NPI Number	:	1083023295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEL A DERMODY H.I.D.

Provider Business Mailing Address
First Line	:	11457 OLDE CABIN RD
Second Line	:	SUITE 337
City	:	CREVE COEUR
State	:	MO
Zip	:	63141-7139
Country	:	US
Telephone Number	:	314-888-6653
Fax Number	:	314-888-6662

Provider Business Practice Location Address
First Line	:	2844 N.SHERIDAN ROAD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657
Country	:	US
Telephone Number	:	773-697-3983
Fax Number	:	773-697-7839

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2014
Last Update Date	:	08/13/2014

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